As a sports physical therapist, I stand alongside athletes facing the formidable challenge of high ankle sprains, a nuanced injury demanding specialized attention. In this guide, we delve deeper into the anatomy, frequency, causes, signs, prognosis, examination, and the crucial aspects of treatment and recovery.

How common are high ankle sprains and what causes them?

High ankle sprains, also known as syndesmotic sprains, account for approximately 10-20% of all ankle sprains. Although they are less common than the more typical lateral ankle sprains, high ankle sprains occur in athletes who engage in high-impact sports such as football, soccer, basketball, ice hockey, and skiing.

The primary causes include:

• Twisting or Rotational Forces: A common mechanism is when the foot is planted on the ground, and an external force causes the leg to twist. This rotation can stress the ligaments of the syndesmosis.

• Direct Impact: A direct blow to the lateral aspect of the leg can force the bones apart, injuring the syndesmotic ligaments.

• Hyperdorsiflexion: Excessive upward bending of the foot can also separate the tibia and fibula, damaging the syndesmosis.

These injuries are more severe and take longer to heal than lateral ankle sprains, often requiring a more extended period of rest and rehabilitation.

How do I tell if I have a high ankle sprain?

Recognizing the signs of a high ankle sprain involves understanding its unique symptoms and comparing them to those of a typical lateral ankle sprain. Here are key indicators:

1. Pain Location: Pain is primarily located above the ankle joint, between the tibia and fibula, rather than around the outer ankle. This area is usually tender to touch.

2. Swelling: Swelling may be present but is typically less pronounced compared to lateral ankle sprains. Swelling is usually located above the ankle joint rather than around it.

3. Difficulty Bearing Weight: Individuals often experience significant pain and difficulty when trying to bear weight on the affected foot. Walking, running, or standing can be challenging and painful.

4. Pain with Rotation: Pain is exacerbated by activities that involve twisting or rotating the foot. This is a key differentiator from lateral ankle sprains, where pain is more associated with side-to-side movements.

5. Instability: A feeling of instability or weakness in the ankle joint is common. This can make it feel like the ankle might give way during movement.

6. Bruising: Bruising may occur, but it's generally less common than with lateral ankle sprains. If present, bruising is usually located above the ankle joint.

7. Positive Squeeze Test: Applying pressure to the lower leg just above the ankle, squeezing the tibia and fibula together, often elicits pain in individuals with a high ankle sprain.

8. Positive External Rotation Test: Rotating the foot externally while the knee is bent at 90 degrees can cause pain if a high ankle sprain is present.

If you suspect a high ankle sprain, it's essential to seek medical evaluation. Diagnosis is often confirmed through physical therapy examination and potentially X-rays or MRI to assess the extent of the injury.

Rehabilitation and Treatment Tailored to Severity

Treatment for high ankle sprains varies based on the injury's severity and the presence of joint instability. That is why it is important to always seek professional medical advice. Our free, 15-minute consultations are an excellent opportunity for patients to discuss their treatment options and understand the recovery process. Here's a breakdown of how your rehabilitation might look depending on the severity of the sprain:

• Grade 1 Injuries: These mild sprains usually respond well to non-operative measures. Treatment includes wearing a boot and resting for 1 to 3 weeks, followed by physical therapy to restore strength and mobility.

• Grade 2 Injuries: For moderate injuries, conservative treatment may be effective if the ankle is stable. However, surgery is often recommended to ensure proper healing and prevent future instability.

• Grade 3 Injuries: Severe sprains, particularly those involving fractures, typically require surgical fixation. The primary goal is to restore stability to the ankle joint.

In general, we can bucket rehabilitation for high ankle sprains into three distinct phases, each designed to address the healing and strengthening of the injured ligaments:

1. Acute Phase: This initial phase focuses on protecting the joint and minimizing pain, swelling, and muscle atrophy. A boot may be used for 1 to 3 weeks to offload the ankle and prevent excessive motion. Pain-free isometric exercises are ideal, and it is crucial to avoid stretching the ankle into painful positions.

2. Subacute Phase: The goal during this phase is to normalize range of motion, strength, and basic function. Achieving symmetry in strength and range of motion between both sides is critical. Balance training on various surfaces is emphasized, and at the end of this phase, patients are assessed for pain during hopping activities.

3. Advanced Phase: This final phase prepares athletes for a return to sports. It incorporates higher-level neuromuscular training, agility drills, and sport-specific tasks. The ultimate goal is to get the athlete back to their sport and daily activities they enjoy.

Long-term Outlook after High Ankle Sprain

The recovery period for high ankle sprains varies significantly, with some athletes facing extended timelines. While many athletes eventually return to their sports, some may not achieve their previous performance levels.

A structured three-stage rehabilitation approach—acute, subacute, and advanced—caters to the unique needs at each phase, facilitating a gradual return to peak performance. The acute phase focuses on immediate pain and swelling management, the subacute phase aims at restoring strength and range of motion, and the advanced phase prepares the athlete for a return to sports-specific activities.

In conclusion, high ankle sprains present complex challenges that require comprehensive understanding and personalized care. By exploring the anatomy, recognizing early signs, pursuing accurate diagnosis and treatment, and committing to a thorough rehabilitation plan, athletes can overcome the obstacles posed by high ankle sprains and strive for a successful return to their sport.